Representation of Health Care Facilities

Medicare or Medicaid Audits and Investigations
Home Health Agencies
Health Care Clinics, Ambulatory Surgery Centers, and Pain Clinics
Peer Review
Medical Staff Credentialing
HIPAA and Patient Confidentiality Issues
Risk Management and Code 15 Reports
National Practitioner Data Bank Reports
Third-Party Insurance Billing Issues
False Claims and Qui Tam Litigation
DEA Registration Issues
Guardianships and Patient Health Care Directives
Hospital Patient Discharge Issues

Medicare or Medicaid Audits and Investigations

Providers are often audited for alleged Medicare or Medicaid overpayments. We provide representation for these audits and investigations, including those by ZPIC's and PSC's. In some cases, we coordinate with medical or coding experts. Audits may stem from deficient documentation, deficient coding, ambiguous Medicare or Medicaid manual guidelines, and other billing issues that expose physicians and facilities to tremendous overpayment obligations. It is our role to explain and justify alleged overpayments to the greatest extent possible, or to represent our clients in hearings before Administrative Law Judges. Obtaining assistance early in the process is critical because Medicaid and Medicare often impose overpayments by extrapolating from alleged billing irregularities based on a relatively small sample. As such, it is frequently beneficial that counsel and experts thoroughly review aspects of patient records to attack and minimize any overpayment exposure.

As South Florida has become known as a hotbed of Medicare and Medicaid fraud, in some cases, rather than simply seeking return of an overpayment, providers are criminally investigated and charged with health care fraud, or their provider numbers are revoked. With our experience in criminal and administrative cases, we are able to handle these cases for our clients in any of these arenas. Understanding that a potential ramification of a fraud conviction or termination from Medicare of Medicaid can lead to non-renewal of a health care license, close coordination of criminal and administrative proceedings is central to our efforts to optimize results for our clients.

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Home Health Agencies

We represent Home Health Agencies for Agency for Health Care Administration (AHCA) state license issues and for compliance with Medicare's Conditions of Participation. We also represent Home Health Agencies in conjunction with audits by Medicare or Medicaid seeking the reimbursement of alleged overpayments. This representation includes requests for redeterminations to Medicare contractors and trials before Administrative Law Judges assigned by the Office of Medicare Hearings and Appeals or Florida's Division of Administrative Hearings (DOAH).

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Health Care Clinics, Ambulatory Surgery Centers, and Pain Clinics

We provide representation for issues regarding the regulation and licensure of Health Care Clinics, Ambulatory Surgery Centers, and Pain Clinics by Florida's Agency for Health Care Administration (AHCA) or Department of Health (DOH). These issues may include a determination of whether a state license is necessary, or for issues pertaining to the issuance or monitoring of the license by AHCA or the DOH. We represent health care facilities or providers pertaining to audits and investigations alleging a failure to comply with licensure requirements, and the alleged disqualification by the State of licensed professionals working at facilities.

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Peer Review

We represent hospitals and ambulatory surgery centers in conjunction with peer review investigations and actions. This representation may include proceedings before peer review committees or advising facilities regarding peer review issues. Peer review proceedings can involve a number of different subject areas including allegations of deviations from the standard of care, qualifications for certain types of privileges, and alleged misrepresentations on medical staff applications. Adverse peer review actions may have significant ramifications upon practitioners which may include the facility's obligation to submit reports of adverse decisions to licensing authorities or the National Practitioner Data Bank.

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Medical Staff Credentialing

We provide representation to hospitals and ambulatory surgery centers pertaining to medical staff credentialing issues. This representation may include the qualification of practitioners to be granted certain privileges, and the interpretation or drafting of medical staff bylaws and medical staff rules and policies.

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HIPAA and Patient Confidentiality Issues

HIPAA regulations can be confusing. Beginning with the enactment of the HIPAA Privacy Rules in 2002, we have created HIPAA compliance programs for large and small health care providers. We have also defended allegations of HIPAA and state privacy law violations brought by government regulators, or brought by patients. We have years of experience working with HIPAA and Florida patient confidentiality laws, and help our clients to avoid legal liability based upon patient privacy violations.

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Risk Management and Code 15 Reports

We represent hospitals and ambulatory surgery centers to comply with risk management requirements imposed by Florida law. For many years, the attorneys at our firm have advised numerous facilities regarding Code 15 reporting requirements. These requirements include the necessity of risk managers to file Code 15 reports with the State as result of certain types of adverse medical incidents. Risk managers are also required to submit reports when there is an allegation of sexual misconduct by a licensed health care provider involving a patient.

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National Practitioner Data Bank Reports

We advise health care facilities regarding National Practitioner Data Bank reporting issues. This representation includes determining whether certain incidents require the filing of a National Practitioner Data Bank report, and the required content of the reports.

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Third-party Insurance Billing Issues

We represent health care providers when insurance companies refuse to pay justifiable bills or seek return of substantial payments alleging improper or insufficient documentation, alleging services were not rendered, that services billed were not medically justified, or were coded improperly. Health insurance carriers' fraud investigation units sometimes refer billing claims they believe were up-coded to the Department of Health to initiate a license disciplinary investigation, and we defend these types of cases. When appropriate to assist our clients, we work with coding experts and other professionals to justify our client's billing, to ensure that insurance companies comply with the prompt pay requirements, and to reduce any requested overpayment amounts.

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False Claims and Qui Tam Litigation

Both the Federal and Florida False Claims Act ("Qui Tam") provide substantial financial incentives for persons who, noting fraudulent wrongdoing related to health care fraud and other types of government contracts, comply with the necessary procedural steps to bring these activities to the government's notice. The attorneys at Rodriguez, & Perry are available to prosecute or defend whistleblower/Qui Tam cases.

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DEA Registration Issues

Pharmacies, drug distributors, narcotics treatment programs, and hospitals cannot distribute or dispense controlled substances without a DEA registration. We represent health care businesses with issues involving the DEA, including the loss of a DEA registration, DEA inspections, and applications for the issuance or renewal of a DEA registration.

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Guardianships and Patient Health Care Directives

We represent hospitals in obtaining guardianships for patients unable to make health care decisions due to incapacity. We also provide legal counsel regarding patient health care directives, and the decisions of health care proxies.

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Hospital Patient Discharge Issues

We represent hospitals regarding discharge issues involving patients who, usually at the insistence of family members, refuse to leave hospitals despite no longer requiring hospital care. Some of our cases have required the filing of litigation when patients refuse to leave.

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